Inequalities in assisted reproduction technology utilisation between the G20 countries

Large global inequalities in assisted reproduction technology (ART) utilisation have existed ever since the introduction of ART. The reasons for these inequalities are multifactorial and include national wealth and affordability, pronatalist policies, regulatory differences in provision, and sociocultural components such as racial, gender and educational inequalities. Examining ART utilisation across the largest world economies (G20 countries) in 2016 (the most recent year with publically available data) reveals significant inequality, which is highly correlated to gross domestic product per capita, a measure of national wealth, and to provision of government funding and/or insurance coverage for in vitro fertilisation and intracytoplasmic sperm injection. A strong negative correlation with the Gender Inequality Index is also noted. The gap in ART utilisation rate will only begin to close once the majority of nations introduce more affordable ART treatment, instigate pronatalist policies, and implement changes in education, attitudes and behaviours to minimise racial and gender inequalities; however, achieving all of these changes may be a very difficult target to attain for many poorer economies, regardless of their size.

Delayed pregnancy detection and return to fertility with extended levonorgestrel-containing oral contraceptives: A real world setting cohort study

PURPOSE

As part of the European risk management plan of a 91-day extended levonorgestrel-containing combined oral contraceptive (COC_LNG ), a study was performed to assess its safety. This analysis was conducted to examine delayed pregnancy detection and return to fertility with extended combined oral contraceptives (COC).

METHODS

We conducted a retrospective cohort study in new users of 91-day COC_LNG or 28-day COC_LNG within a US-based healthcare claims database from 2006 to 2017. Delayed pregnancy detection during current COC_LNG exposure was defined as the time between estimated pregnancy start and first prenatal care encounter. Additionally, the time between estimated pregnancy start and COC_LNG discontinuation was measured. To measure return to fertility, pregnancy rates were estimated among females who discontinued treatment. 91-day COC_LNG users were propensity score-matched to 28-day COC_LNG users. Hazard ratio for pregnancy was calculated using Cox proportional hazards models.

RESULTS

The 91-day and 28-day COC_LNG users had 25 593 and 76 586 treatment episodes, respectively. The median time to pregnancy detection was 64.5 and 61.0 days (p = 0.24) in users of 91-day COC_LNG and 28-day COC_LNG . The median exposure time to treatment after estimated pregnancy start was 54.0 and 38.0 days (p < 0.01). In the fertility analysis, pregnancy rates were 54.82 (95% CI, 50.05-59.93) and 69.30 (95% CI, 64.98-73.82) per 1000 person-years in extended COC_LNG discontinuers and 28-day COC_LNG discontinuers. The adjusted hazard ratio of pregnancy was 0.77 (95% CI, 0.69-0.85).

CONCLUSIONS

Small differences were observed for pregnancy rates and delayed pregnancy detection between 91-day extended COC_LNG and 28-day COC_LNG , which may be related to the longer days' supply of extended COC_LNG . Differences in the fertility analysis may be related to unmeasured residual confounding.

Long-term safety of extended levonorgestrel-containing oral contraceptives in the United States

OBJECTIVES

To compare the safety profile of Seasonique, a 91-day levonorgestrel-containing combined oral contraceptive (COC_LNG), to 28-day COC_LNG regarding the risk of venous thromboembolism (VTE) and arterial thromboembolism (ATE).

STUDY DESIGN

A new user cohort study was conducted in a US health care database from 2006 to 2017. Each 91-day COC_LNG treatment episode in females was matched to up to four 28-day COC_LNG treatment episodes by propensity score. We identified VTE cases in either (1) an inpatient setting with ICD-9 and ICD-10 diagnosis codes of PE and/or DVT in the primary position, or (2) an outpatient setting with ICD-9 or ICD-10 diagnosis codes of DVT in conjunction with an anticoagulant medication dispensing or alteplase (thrombolytic) during the 30-day period following the date of DVT diagnosis. VTE was validated using medical records. We assessed the study endpoints in the two cohorts using incidence rates and Cox proportional hazards models adjusted for potential confounders.

RESULTS

Of the 25,593 treatment episodes in 91-day COC_LNG and 76,586 treatment episodes in 28-day COC_LNG, 35 and 68 patients had VTEs, respectively, corresponding to a hazard ratio (HR) of 1.40 (95% confidence interval [CI], 0.90-2.19). The VTE algorithm had a positive predictive value of 76.4% (95% CI, 66.2%-84.8%). ATEs were recorded in 13 and 28 episodes, respectively, with a corresponding HR of 1.21 (95% CI, 0.58-2.53).

CONCLUSIONS

These results do not indicate a significant difference between 91-day COC_LNG and 28-day COC_LNG in terms of VTE or ATE risk.

IMPLICATIONS

Compared to use of 28-day COC_LNG, use of 91-day extended COC_LNG was not associated with a significant difference in risk of venous and arterial thromboembolism.

P–731 Correlation between fertility rate, utilisation of ART and gross domestic product across Europe

Study question

Are there any correlations between a country’s wealth determined by GDP per capita and its total fertility rate (TFR) and utilisation of ART in Europe?

Summary answer

There is strong correlation across Europe between GDP and utilisation of ART. This correlation does not exist when only investigating the European Economic Area (EEA)

What is known already

The number of documented ART cycles has increased significantly from 203,893 cycles in 1997 (first European report) to 918,159 in 2016. During the same period, growth was observed in European GDP and, to a lesser extent, TFR following a significant and prolonged decline. Global data suggest that utilisation rate is higher in developed countries, speculated to be due to either generous reimbursement systems or higher affordability for patients paying out of pocket. This study analysed for the first time the relationships between national GDP, TFR and utilisation in Europe both as a whole, and specifically the more affluent EEA

Study design, size, duration

This study was an analysis of publicly available primary international reports: total cycles in the European IVF-monitoring Consortium (EIM) and TFR, GDP and population size from the World Bank indicators (https://data.worldbank.org/indicator). The period studied ranged from the first EIM report for 1997 (published in 1999) to the 20th report for 2016 (published in 2020).

Participants/materials, setting, methods

TFR was described as births per women (BPW) and country wealth was presented as GDP per capita in US Dollars. Utilisation rate was defined as the total national number of cycles (fresh IVF and ICSI, and frozen embryo transfer) divided per population, and presented as cycles per million (CPM). When utilisation was not reported, total cycles were projected by proportional calculation. Pearson Correlations were calculated using Sigmaplot for utilisation, GDP and TFR in 2016

Main results and the role of chance

Forty countries were included in the EIM report for 2016, of which 18 reported in full. The median utilisation rate was 1280 CPM (range 162 - 3,156) and median TFR was 1.6 BPW (range 1.26 - 2.73); only one country, Kazakhstan, had a TFR above the natural fertility replacement level of 2.1 BPW. Mean GDP was $31604 per capita (range $10,610 - $110,650). There was no correlation between TFR and utilisation or between TFR and GDP, however there was a significant positive correlation between GDP and CPM (correlation coefficient = 0.428; P = 0.00661). Compared to Europe as a whole, analysis of only the EEA countries – EU member states plus Norway, Iceland, and Switzerland – revealed a similar median TFR (1.59), but a 27% increase in the utilisation rate to 1629 CPM (range: 317 – 3157) and 24% rise in GDP per capita to $39,300 (range: $19,885- $110,650). For the EEA, no significant correlations were observed, including between GDP and utilisation (correlation coefficient = 0.131; P = 0.507). Additionally, there was no significant correlation between TFR and GDP in the EU for the period of 1997 – 2016.

Limitations, reasons for caution

The data is a snapshot of a single year, but we observed similar outcomes in previous years. Projection calculation of utilisation in partially reporting countries may cause bias, however, with a reporting level of 92% (1347 of 1467 clinics), this bias is probably very limited.

Wider implications of the findings: Findings of this study confirm that there are strong disparities in the availability of ART even in Europe. This difference does not exist in the more affluent countries in Europe suggesting that the reason for lower utilisation in lower-income countries being reduced affordability.

Trial registration number

NA

P–592 Safety and effectiveness of follitropin alfa biosimilar to originator follitropin alfa in real-world clinical practice: A Multinational Comparative, Prospective Cohort Study

Study question

Are safety and effectiveness of Ovaleap® (follitropin alfa), and Gonal-f®, comparable in one treatment cycle of ART in routine clinical practice?

Summary answer

Safety in terms of incidence proportions of OHSS and OHSS severity, as well as pregnancy and live birth rates, were similar between Ovaleap® and Gonal-f®.

What is known already

Ovaleap® (Theramex), a r-hFSH, is a biosimilar medicinal product to Gonal-f® (Merck). As a biosimilar, it went through a rigorous series of physio-chemical, in vitro, in vivo tests and confirmatory Phase I and III studies, to demonstrate similarity/equivalence in quality, safety and efficacy to the reference medicinal product, per the European Medicines Agency (EMA) guidelines. Ovaleap® was approved by the EMA in 2013 for use at the same dose and for the same therapeutic indications as Gonal-f®. Further outcome data from a broader patient population on safety and live birth outcomes provides clinically important insights on newly introduced FSH medicines.

Study design, size, duration

SOFIA (Safety of Ovaleap® Follitropin alfa in Infertile women undergoing superovulation for Assisted reproductive technologies) was a multi-national, comparative, non-interventional, prospective cohort study. The study was performed at 56 centers specializing in ART from six European countries, (Belgium, France, Germany, Italy, Spain, and the United Kingdom) from January 2017 to September 2019 and comprised of 817 infertile women undergoing controlled ovarian hyperstimulation in one treatment cycle for ART

Participants/materials, setting, methods

The study population comprised of infertile women undergoing controlled ovarian hyperstimulation for ART, who were administered Ovaleap® or Gonal-f® and were naïve to any FSH containing products. Eligible patients were enrolled at a ratio of approximately 1:1, both within and between countries. They were followed up to 30 days after the last FSH dose administration. Women who had a confirmed clinical pregnancy were followed until the end of the pregnancy or until delivery.

Main results and the role of chance

A total of 408 and 409 women who were administered Ovaleap® or Gonal-f®, respectively, were eligible for analysis. A total of 382 patients (94%) in the Ovaleap® and 390 patients (95%) in the Gonal-f® cohort completed FSH treatment (up to oocyte maturation triggering), respectively. The two cohorts were generally similar with regard to demographic and baseline characteristics. The incidence proportion of OHSS was 5.1% (95% CI: 3.4, 7.7) in the Ovaleap® and 3.2% (95% CI: 1.9, 5.4) in the Gonal-f® cohort. This difference in OHSS incidence proportion between the two cohorts was not statistically significant neither before (p = 0.159) nor after univariate adjustment for each potential confounder (p &gt; 0.05). The incidence proportion of OHSS severity grades was similar in the two treatment groups (3.4% versus 2.0% for Grade I, 1.2% versus 1.0% Grade II, and 0.5% versus 0.2% Grade III, in the Ovaleap® and Gonal-f® cohorts, respectively) and without a significant statistical difference (p = 0.865, for each grade). Among patients who had embryo transfer, clinical pregnancy rates were 33% and 31%, live birth rates 27% and 26% in the Ovaleap® and Gonal-f® cohorts, respectively.

Limitations, reasons for caution

Since treatment was non-randomised, the study may have been susceptible to selection bias. This was addressed at both the design stage, by balancing recruitment to a 1:1 ratio for Ovaleap® and Gonal-f® treatments, and also at the analysis stage in which, a univariate analysis was performed.

Wider implications of the findings: Findings from this first large European prospective comparative real-world SOFIA study demonstrated that effectiveness (pregnancy and delivery rates) and safety (risk and severity of OHSS), were similar between Ovaleap®and Gonal-f® treatments. Ovaleap, a biosimilar r-hFSH is therefore a suitable option for follicular stimulation in routine clinical practice.

Trial registration number

EUPAS17328

Real world utilization of 91 day extended levonorgestrel-containing combined oral contraceptives in Europe: a multinational database study

OBJECTIVE

As part of the risk management plan in Europe, this study was conducted to characterize drug utilization patterns of Seasonique, a 91 day extended levonorgestrel-containing combined oral contraceptive (COC_LNG).

METHODS

A retrospective observational study was conducted in France, Italy and Belgium using electronic medical record databases obtained from general practitioners (GPs) in all participating countries and gynecologists in France from 2015 to 2018. The study population included women receiving ≥1 prescription of 91 day COC_LNG during the study period. Prescribing patterns of 91 day COC_LNG were examined including: (1) treatment duration; (2) indication; (3) use of combined oral contraceptive (COC) before 91 day COC_LNG initiation; and (4) switch from and to combined hormonal contraceptives (CHCs) or other contraceptives.

RESULTS

Totals of 235, 220, 207 and 659 women using 91 day COC_LNG were identified in French, Italian and Belgian GP, and French gynecologist databases, respectively. Across databases, 46-76% of women were prescribed a single 91 day COC_LNG prescription and median treatment duration ranged from 3 to 6 months. The most common indication was contraception (42-81%), followed by menstrual migraines (2-14%). Use of COC during the 6 months prior to 91 day COC_LNG initiation was 14% across GP databases, but was lower (8%) in the French gynecologist database. The frequency of switching from 91 day COC_LNG to CHCs or other contraceptives was generally low (5-12%), with the highest proportion being among patients of French gynecologists.

CONCLUSIONS

Findings indicate that 91 day COC_LNG was prescribed for relatively short durations and predominantly as indicated for contraception. Most results were comparable across all participating countries. KEY POINTSFindings from this drug utilization study in European databases across general practitioners and French gynecologists confirmed that 91 day extended levonorgestrel-containing combined oral contraceptive (COC_LNG) was prescribed for relatively short durations (median 3-6 months); predominantly for the intended indication of contraception.Combined oral contraceptive use during the 6 months prior to 91 day COC_LNG initiation, and switching from 91 day COC_LNG to combined hormonal contraceptives or other contraceptives, were generally low (14% or less).These findings were mostly consistent across participating countries.

Is there a correlation between total fertility rate, utilization of assisted reproduction technology, and national wealth in Europe?

AIM

To explore the relationships between total fertility rate (TFR), utilization of assisted reproduction technology (ART), and gross domestic product (GDP) per capita in Europe.

MATERIALS AND METHODS

Analysis of total ART cycles obtained from the latest European IVF-Monitoring Consortium (EIM) report for 2016. TFR, GDP and population size for that year were found in relevant World Bank data documents. In addition, this study compared two subgroups in Europe: developed economies and economies in transition, as defined by the UN. Pearson Correlations were calculated using Sigmaplot for utilization, GDP and TFR.

RESULTS

Forty countries were included in the 2016 EIM report. The mean utilization rate was 1,391 cycles per million population (C/M) (range = 162-3156) and mean TFR was 1.61 (range = 1.26-2.73). Mean GDP was $35,072 per capita (range = $10,610-$110,650). There was no correlation between TFR and utilization or GDP, however there was a significant positive correlation between GDP and utilization (correlation coefficient = 0.428; p = 0.00661). In the developed economies (n = 28) GDP and utilization were roughly 3-times higher than in the economies in transition (n = 11) ($42,710 vs $15,630; 1,674 vs 671), with a slightly lower TFR (1.58 vs 1.67). In the developed economies there was no correlation between GDP, TFR, and utilization, while in the economies in transition, the only significant correlation was GDP vs TFR (r = 0.69; p = 0.017).

CONCLUSIONS

There is a strong correlation across Europe between GDP and utilization of ART. This correlation does not exist within the developed economies. In Europe the utilization of ART treatment is dependent on national wealth and not on the TFR in the country.

Safety of Ovaleap® (Follitropin Alfa) in Infertile Women Undergoing Superovulation for Assisted Reproductive Technologies: A Multinational Comparative, Prospective Cohort Study

BACKGROUND

Ovaleap^® (follitropin alfa), a recombinant human follicle stimulating hormone, is a biosimilar medicinal product to Gonal-f^® and is used for ovarian stimulation. The main objective of this study was to assess the safety and effectiveness of Ovaleap^® compared to Gonal-f^® in one treatment cycle in routine clinical practice.

METHODS

Safety of Ovaleap^® Follitropin alfa in Infertile women undergoing superovulation for Assisted reproductive technologies (SOFIA) was a prospective cohort study conducted in six European countries. Eligible patients were infertile women undergoing superovulation for assisted reproductive technology, who were administered Ovaleap^® or Gonal-f^® for ovarian stimulation and were naïve to follicle stimulating hormone treatment. The recruitment ratio was 1:1. The primary endpoint was incidence proportion of ovarian hyperstimulation syndrome (OHSS) and the secondary endpoint was OHSS severity (Grades I, II, III). The effect of risk factors or potential confounders on the odds ratio for OHSS incidence as well as treatment effect on OHSS incidence was explored using univariate logistic regression. Pregnancy and live birth rates were also assessed.

RESULTS

A total of 408 women who were administered Ovaleap^® and 409 women who were administered Gonal-f^® were eligible for analysis. The incidence proportion of OHSS was 5.1% (95% CI: 3.4, 7.7) in the Ovaleap^® cohort and 3.2% (95% CI: 1.9, 5.4) in the Gonal-f^® cohort. This difference in OHSS incidence proportion between the two cohorts was not statistically significant neither before (p = 0.159) nor after univariate adjustment for each potential confounder (p > 0.05). The incidence proportion of OHSS severity grades was similar in the two treatment groups (3.4% versus 2.0% for Grade I, 1.2% versus 1.0% for Grade II, and 0.5% versus 0.2% for Grade III, in the Ovaleap^® and Gonal-f^® cohorts, respectively), without a significant statistical difference (p = 0.865, for each grade). Among patients who had embryo transfer, clinical pregnancy rates were 33% and 31% and live birth rates were 27% and 26%, in the two cohorts, respectively.

CONCLUSIONS

Findings from the SOFIA study indicate that the incidence proportions of OHSS and OHSS severity, as well as pregnancy and live birth rates, are similar between Ovaleap^® and Gonal-f^® treatments and corroborate the safety and effectiveness of Ovaleap^® as a biosimilar to Gonal-f^®.

Correlation between gross domestic product, utilization of in vitro fertilization, and pregnancy success rate across the world

Background: IVF is now a wide spread procedure globally, and currently 65 countries report annually all or part of their IVF/ICSI cycles, from which the International Committee Monitoring progress in Assisted Reproduction Technology (ICMART) published its report. There is considerable variation in the utilization (number of cycles per population) globally. Aims: The objectives of this study were to assess whether utilization is related to national wealth, presented as gross domestic product (GDP), and whether the GDP has any effect on success in IVF treatment, mainly delivery and clinical pregnancy rates. Results: The results demonstrated a significant positive correlation between utilization and GDP (CC = 0.563, p = 0.00000194), and both utilization and GDP have strong negative correlations to successful outcome of the treatment-clinical pregnancy rate (CC: -0.460, p = 0.00015; CC: -0.399, p = 0.0012, respectively) and delivery rates (cc = -0.396, p = 0.00484; cc = -0.3, p = 0.0179, respectively). Conclusions: Poor nations have less utilization of IVF, probably due to the limited affordability of the treatment, but reassuringly do not seem to have less success in the treatment. Further research is required to fully understand the implications of these correlations and to better design national and international fertility policies.

Omega-3 polyunsaturated fatty acids and IVF treatment

Omega-3 polyunsaturated fatty acids (PUFAs) are essential fatty acids, derived mostly from fish oil, that have a significant anti-inflammatory effect. Data from animal studies support their role in the reproductive mechanism, and recent human studies suggest a positive effect on sperm quality and natural conception. Their general role in human fertility, and specifically in IVF treatment, however, is not clear. A few small, prospective cohort studies have examined the relationship between serum PUFAs and outcome measures and success in IVF, with conflicting results. Some have demonstrated a better chance of live birth with increased levels of serum omega-3 PUFAs, whereas others have failed to show such a correlation, and the reasons for such differences are not clear. Moreover, no well-designed, published studies have assessing whether the administration of omega-3 PUFAs before IVF treatment can improve clinical pregnancy and live birth rates. The development of safe and well-tolerated pharmaceutical forms of the active omega-3 PUFAs, docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), mean that assessment of this question is now possible and future studies are warranted.

The patient burden of opioid-induced constipation: New insights from a large, multinational survey in five European countries

BACKGROUND

Despite its high prevalence, opioid-induced constipation (OIC) remains under-recognised and undertreated, and its true impact on wellbeing and quality of life (QoL) may be underestimated.

METHODS

A quantitative, questionnaire-based international survey was conducted.

RESULTS

Weak-opioid users appeared as bothered by constipation as strong-opioid users (38% vs 40%, respectively; p = 0.40), despite it causing less-severe physical symptoms and impact on QoL. Strong-opioid users meeting Rome IV OIC criteria appeared to experience greater symptomatic and biopsychosocial burden from constipation than those not satisfying these criteria. Almost one-fifth of respondents were dissatisfied with their current constipation treatment and around one-third found balancing the need for adequate pain relief with constipation side effects challenging. Consequently, more than half failed to adhere to their prescribed treatment regimens, or resorted to suboptimal strategies, e.g. 40% reduced their opioid intake, to relieve constipation. Almost 60% of healthcare professionals did not adequately counsel patients about constipation as a common side effect of opioid use.

CONCLUSIONS

Findings suggest that both weak- and strong-opioid users suffer comparable bother and decreased QoL, Rome IV criteria can identify patients with more-severe OIC, but may underdiagnose patients showing fewer symptoms, and increased education is needed to manage patients' expectations and enable improved OIC self-management.

Monoglyceride lipase deficiency causes desensitization of intestinal cannabinoid receptor type 1 and increased colonic μ-opioid receptor sensitivity

Background and Purpose

Monoglyceride lipase (MGL) degrades 2-arachidonoyl glycerol (2-AG), an endogenous agonist of cannabinoid receptors (CB_1/2). Because the CB₁ receptor is involved in the control of gut function, we investigated the effects of pharmacological inhibition and genetic deletion of MGL on intestinal motility. Furthermore, we determined whether defective 2-AG degradation affects μ-opioid receptor (μ receptor) signalling, a parallel pathway regulating gut motility.

Experimental Approach

Gut motility was investigated by monitoring Evans Blue transit and colonic bead propulsion in response to MGL inhibition and CB₁ receptor or μ receptor stimulation. Ileal contractility was investigated by electrical field stimulation. CB₁ receptor expression in ileum and colon was assessed by immunohistochemical analyses.

Key Results

Pharmacological inhibition of MGL slowed down whole gut transit in a CB₁ receptor-dependent manner. Conversely, genetic deletion of MGL did not affect gut transit despite increased 2-AG levels. Notably, MGL deficiency caused complete insensitivity to CB₁ receptor agonist-mediated inhibition of whole gut transit and ileal contractility suggesting local desensitization of CB₁ receptors. Accordingly, immunohistochemical analyses of myenteric ganglia of MGL-deficient mice revealed that CB₁ receptors were trapped in endocytic vesicles. Finally, MGL-deficient mice displayed accelerated colonic propulsion and were hypersensitive to μ receptor agonist-mediated inhibition of colonic motility. This phenotype was reproduced by chronic pharmacological inhibition of MGL.

Conclusion and Implications

Constantly elevated 2-AG levels induce severe desensitization of intestinal CB₁ receptors and increased sensitivity to μ receptor-mediated inhibition of colonic motility. These changes should be considered when cannabinoid-based drugs are used in the therapy of gastrointestinal diseases.

Endothelialization of electrospun polycaprolactone (PCL) small caliber vascular grafts spun from different polymer blends

Small caliber vascular grafts represent a challenge to material scientists. In contrast to large caliber grafts, prostheses with diameter <6 mm, lead to increased hemodynamic disturbances and thrombogenic complications. Thus, endothelialization of small caliber grafts should create a compatible interface for hemodynamic processes. The purpose of our study was to compare different compositions of electrospun scaffolds with conventional ePTFE grafts with an inner diameter of 4 mm as well as different pre-coatings to create an optimized physiological interface for endothelialization. Polycaprolactone, polylactide, and polyethylenglycol (PCL/PLA and PCL/PLA/PEG) electrospun grafts and ePTFE grafts were pre-coated with blood, gelatine or fibronectin and seeded with endothelial cells from the human term placenta. Best results were obtained with fibronectin-coated PCL/PLA/PEG grafts. Here, the number of attached viable cells was 78-81% higher than on fibronectin pre-treated ePTFE grafts. Cells attached to PCL/PLA/PEG grafts appeared in physiological cobblestone morphology. Viability analysis showed a high cell viability of more than 98%. Fibronectin-coated PCL/PLA/PEG grafts may be a promising improvement to conventionally used ePTFE grafts.

The first detection of Toxoplasma gondii DNA in environmental fruits and vegetables samples

Toxoplasma gondii infections are prevalent in humans and animals all over the world. The aim of the study was to estimate the occurrence of T. gondii oocysts in fruits and vegetables and determine the genotype of the parasites. A total number of 216 fruits and vegetables samples were taken from shops and home gardens located in the area of northern Poland. Oocysts were recovered with the flocculation method. Then, real-time polymerase chain reaction (PCR) targeting the B1 gene was used for specific T. gondii detection and quantification. Toxoplasma DNA was found in 21 samples. Genotyping at the SAG2 locus showed SAG2 type I and SAG2 type II. This is the first investigation describing T. gondii DNA identification in a large number of fruits and vegetables samples with rapid molecular detection methods. The results showed that fruits and vegetables contaminated with T. gondii may play a role in the prevalence of toxoplasmosis in Poland.

A large Northern European observational study of follitropin alpha filled-by-mass pre-filled pen

This prospective observational post-marketing survey aimed at studying the efficacy and convenience of the follitropin alpha filled-by-mass (FbM) pre-filled pen for patients in routine use. These data were analysed among 3196 non-selected treatment cycles and couples in seven Northern European countries. Valuable information was also obtained regarding the routine assisted reproduction treatment protocols used in Northern Europe. Out of 3196 cycles, human chorionic gonadotrophin (HCG) was administered in 3104 (97.2%), and an embryo transfer was carried out in 2766 cycles (86.5%). A positive HCG was recorded in 997 cycles (31.2% per started cycle and 36.0% per embryo transfer). The overall clinical pregnancy rate was 23.1% (738/3196) and per embryo transfer it was 26.7% (738/2766), with a miscarriage rate of 3.4% (95/2766) per embryo transfer or 9.5% (95/997) per positive HCG. Among the 732 elective single embryo transfers (eSET), the rate of positive HCG was 38.0% and the clinical pregnancy rate was 29.6%, suggesting that eSET is a valuable option in routine assisted reproduction. Although minor differences were observed between countries, the follitropin alpha FbM pre-filled pen proved clinically effective, was generally well tolerated, and both the women and nurses/midwives found the training easy.

Effects of recombinant LH treatment on folliculogenesis and responsiveness to FSH stimulation

BACKGROUND

The role of LH in sensitizing antral follicles to FSH is unclear. LH is required for normal hormone production and normal oocyte and embryo development, but follicular responses to LH may depend upon the stage of development. Potential roles at the early follicular phase were explored in a clinical setting by employing a sequential approach to stimulation by recombinant human (r-h) LH followed by r-hFSH in women who were profoundly down-regulated by depo GnRH agonist.

METHODS

We employed a multi-centre, prospective, randomized approach. Women (n = 146) were treated in a long course high-dose GnRH agonist (Decapeptyl, 4.2 mg s.c.) protocol and were randomized to receive r-hLH (Luveris, 300 IU/day) for a fixed 7 days, or no r-hLH treatment. This was followed by a standard r-hFSH stimulation regime (Gonal-F, 150 IU/day). Ultrasound and hormone assessments of responses were measured at the start of r-hLH treatment, on FSH stimulation Days 0 and 8 and at the time of HCG administration.

RESULTS

The LH treatment was associated with increased small antral follicles prior to FSH stimulation (P = 0.007), and an increased yield of normally fertilized (2 PN) embryos (P = 0.03). There was no influence of the r-hLH pretreatment upon hormone profiles or ultrasound assessments during the FSH phase. Anti-mullerian hormone increased in both groups during the week prior to FSH stimulation (P = 0.002).

CONCLUSIONS

This sequential approach to the use of r-hLH in standard IVF showed a possible modest clinical benefit. The results support other recent work exploring up-regulated androgen drive upon follicular metabolism indicating that clinical benefit may be obtainable after further practical explorations of the concept.

Assessment of ovarian reserve: Is there still a role for ovarian biopsy in the light of new data?

Ovarian reserve depends on the number of primordial follicles in the ovarian cortex. It was suggested that determining the follicular density directly by obtaining ovarian biopsy might be more accurate than current indirect biochemical and ultrasonic tests, especially for women in the later stage of their reproductive life. It might also be important and beneficial for young patients having chemotherapy for malignant disease in whom the ovarian tissue should be considered for reimplantation after recovery. The advantages and pitfalls of obtaining ovarian biopsy in these cases are discussed in light of new emerging data on the natural distribution of primordial follicles in the human ovary and its implications.

Routine use of r-hFSH follitropin alfa filled-by-mass for follicular development for IVF: a large multicentre observational study in the UK

The technical advance of recombinant biotechnology to manufacture FSH has resulted in a biochemically pure FSH preparation with high batch-to-batch consistency. The protein content of recombinant human FSH (r-hFSH) can be reliably quantified in mass units by size exclusion high performance liquid chromatography (SE-HPLC) enabling r-hFSH follitropin alfa (Gonal-F) to be filled and released in the vial on the basis of mass with dose variability of only +/-2% [filled-by-mass (FbM)]. Observational studies have merit in addressing the effectiveness of a new product in routine clinical practice. This non-interventional study assessed r-hFSH follitropin alfa FbM for the multifollicular stimulation of patients undergoing assisted reproduction. A total of 1427 patients were recruited in 21 centres in the UK and the mean age was 34.3 years (+/-4.48, range 18-48). Of those who started treatment, 1388 (97.3%) received human chorionic gonadotrophin and 1330 (93.2%) underwent oocyte retrieval. A total of 1213 (85%) patients had embryo transfer and in the majority of recorded cases, most embryos replaced were graded as 1 or 2 (74.6%). The ongoing clinical pregnancy rate was 29.2% per cycle and 34.4% per embryo transfer. The routine use of r-hFSH follitropin alfa FbM in normal clinical practice in IVF has been demonstrated to be effective, safe and well received by patients.

Monitoring of in vitro fertilization-embryo transfer cycles by ultrasound versus by ultrasound and hormonal levels: a prospective, multicenter, randomized study

OBJECTIVE

To determine whether cycle monitoring using both serum E(2) and ultrasound findings yields superior clinical pregnancy rates during IVF-embryo transfer (ET) compared to monitoring with ultrasound alone.

DESIGN

Prospective, randomized, multicenter, patient-blinded study.

SETTING

Four assisted conception units in the United Kingdom.

PATIENT(S)

Two hundred ninety-seven women believed to be normal responders undergoing IVF treatment.

INTERVENTION(S)

Patients were randomly allocated on day 7 of stimulation to one of the two hCG administration criteria: [1] the E(2)-to-follicle > or =11 mm ratio was between 250 and 500 pmol/L/follicle and at least 2 follicles reached a mean diameter of 18 mm or [2] at least 2 follicles reached a mean diameter of 18 mm and the endometrium thickness was > or =8 mm.

MAIN OUTCOME MEASURE(S)

Duration and cumulative dose of recombinant human FSH, total number of growing follicles, oocytes retrieved, number and quality of embryos, pregnancy rates, and ovarian hyperstimulation syndrome (OHSS) rates.

RESULT(S)

Two hundred ninety-seven patients were randomized to one of the two criteria groups. Of these, 288 (97%) received urinary (u)-hCG (143 in group A and 145 in group B). One hundred three women in group A (72%) met both criteria for hCG administration. Pregnancy and OHSS rates were similar (34.3% vs. 31.4% and 4.9% vs. 4.1%, respectively).

CONCLUSION(S)

The addition of E(2)/follicle criteria to ultrasound monitoring of IVF cycles in normal responders seldom changes the timing of hCG, and does not increase pregnancy rates or the risk of OHSS.

Relationship of baseline ovarian volume to ovarian response in World Health Organization II anovulatory patients who underwent ovulation induction with gonadotropins

OBJECTIVE

To assess whether ovarian volume of World Health Organization II anovulatory patients in the early follicular phase predicts the response to ovulation induction with gonadotropins.

DESIGN

Retrospective data analysis of two prospective, randomized, multicenter studies.

SETTING

Clinical development unit of biotechnology company.

PATIENT(S)

Four hundred sixty-five World Health Organization II anovulatory patients undergoing ovulation induction.

MAIN OUTCOME MEASURE(S)

Ovarian response to stimulation, ovulation (mid-luteal serum progesterone > 30 nmol/L), cancellation rate, pregnancy rate, and incidence of the ovarian hyperstimulation syndrome (OHSS) according to baseline ovarian volume (day 2-5) before stimulation.

RESULT(S)

Mean ovarian volume was 11.55 +/- 6.0 cm(3) (range, 0.8-49.3 cm(3)). Small ovarian volume was associated with lower rates of cycle cancellation owing to risk for OHSS (3 vs. 29 patients [2.8% vs. 9%]). Patients with small ovarian volume (<7.25 cm(3)) required fewer ampules of FSH (1373 IU vs. 1629 IU) and shorter duration of stimulation (16 vs. 18.1 days) and had higher ovulation rate than did patients with mid-range and larger ovarian volume (84.3% vs. 69.1% and 68.8%, respectively). The clinical pregnancy rate per cycle of hCG administration was similar in the three groups (25.8%, 28.1%, and 27.5%).

CONCLUSIONS

World Health Organization II anovulatory women with medium-sized or large ovaries who are undergoing low-dose gonadotropin stimulation for ovulation induction may have higher risk for OHSS than do women with small ovaries. Women with small ovaries who meet criteria for administration of hCG respond better to ovulation induction and have a similar likelihood of conceiving compared with women with larger ovaries.

Leukemia inhibitory factor in human reproduction

OBJECTIVE

To describe the clinical findings, expressions, interactions, and clinical implications of leukemia inhibitory factor (LIF) in human reproduction.

DESIGN

Review of published articles.

SETTING

Clinical development unit of biotechnology company.

INTERVENTION(S)

None.

RESULT(S)

In the endometrium, LIF is expressed in a menstrual cycle-dependent manner, with the highest level occurring at the time of implantation. LIF is also detected in uterine flushing, and its level is significantly lower in women with unexplained infertility. Likewise, endometrial explants derived from women with unexplained infertility showed reduced levels of LIF secretion. Binding of LIF to LIF receptor and gp130 activates signal transduction pathways. LIF receptor is expressed in endometrium, oocytes, and blastocysts. Cytotrophoblasts cultured in the presence of LIF differentiate toward an anchoring extravillous phenotype.

CONCLUSION(S)

On the basis of reports gathered from animal and human studies, LIF appears to play an important role in implantation and in the establishment of pregnancy.

Protein tyrosine nitration in mouse peritoneal macrophages activated in vitro and in vivo: evidence against an essential role of peroxynitrite

Tyrosine nitration is considered a key reaction of peroxynitrite-triggered tissue injury in inflammatory diseases. We investigated the potential involvement of peroxynitrite in protein tyrosine nitration in isolated murine peritoneal macrophages activated either in vitro with interferon-gamma/lipopolysaccharide or in vivo by priming mice with Corynebacterium parvum (10 mgxkg-1). Both protocols led to release of NO and accumulation of nitrite accompanied by formation of protein-bound 3-nitrotyrosine. Oxidation of dihydrorhodamine 123, a measure of peroxynitrite release, remained close to basal levels upon in vitro activation of the macrophages but was increased approximately twofold in vivo. Tyrosine nitration in macrophages activated in vitro was inhibited by catalase and the time course of nitration correlated with nitrite accumulation, whereas superoxide (O2*-) and H2O2 release occurred at much earlier times. To address the contribution of O2*- and peroxynitrite to in vivo nitration, a O2*- scavenger (MnTBAP; 1 mgxkg-1) was given to C. parvum-primed mice. MnTBAP led to almost complete inhibition of C. parvum-triggered O2*- and peroxynitrite release, whereas nitrite accumulation and formation of 3-nitrotyrosine were less affected ( approximately 50% of controls). These results argue against an essential role of peroxynitrite in protein tyrosine nitration in vivo.

Protein tyrosine nitration in cytokine-activated murine macrophages. Involvement of a peroxidase/nitrite pathway rather than peroxynitrite

Peroxynitrite, formed in a rapid reaction of nitric oxide (NO) and superoxide anion radical (O(2)), is thought to mediate protein tyrosine nitration in various inflammatory and infectious diseases. However, a recent in vitro study indicated that peroxynitrite exhibits poor nitrating efficiency at biologically relevant steady-state concentrations (Pfeiffer, S., Schmidt, K., and Mayer, B. (2000) J. Biol. Chem. 275, 6346-6352). To investigate the molecular mechanism of protein tyrosine nitration in intact cells, murine RAW 264.7 macrophages were activated with immunological stimuli, causing inducible NO synthase expression (interferon-gamma in combination with either lipopolysaccharide or zymosan A), followed by the determination of protein-bound 3-nitrotyrosine levels and release of potential triggers of nitration (NO, O(2)*, H(2)O(2), peroxynitrite, and nitrite). Levels of 3-nitrotyrosine started to increase at 16-18 h and exhibited a maximum at 20-24 h post-stimulation. Formation of O(2) was maximal at 1-5 h and decreased to base line 5 h after stimulation. Release of NO peaked at approximately 6 and approximately 9 h after stimulation with interferon-gamma/lipopolysaccharide and interferon-gamma/zymosan A, respectively, followed by a rapid decline to base line within the next 4 h. NO formation resulted in accumulation of nitrite, which leveled off at about 50 microm 15 h post-stimulation. Significant release of peroxynitrite was detectable only upon treatment of cytokine-activated cells with phorbol 12-myristate-13-acetate, which led to a 2.2-fold increase in dihydrorhodamine oxidation without significantly increasing the levels of 3-nitrotyrosine. Tyrosine nitration was inhibited by azide and catalase and mimicked by incubation of unstimulated cells with nitrite. Together with the striking discrepancy in the time course of NO/O(2) release versus 3-nitrotyrosine formation, these results suggest that protein tyrosine nitration in activated macrophages is caused by a nitrite-dependent peroxidase reaction rather than peroxynitrite.

Sperm banking and assisted reproduction treatment for couples following cancer treatment of the male partner

In recent years, the survival of young males suffering from cancer has been improved. Development of new techniques such as IVF and intracytoplasmic sperm injection enables even low quality spermatozoa to be used successfully. It is possible therefore to preserve fertility potential of cancer patients before embarking on adjuvant chemotherapy and radiotherapy. Recognizing the importance of protecting the fertility potential of these young males, we present our recommendations for sperm cryopreservation based on the 11 year experience of Bourn Hall and the British Joint Council for Clinical Oncology consultation report. This paper discusses the options available for patients who recover from cancer to become fathers. In many cases patients are concerned about possible abnormalities and teratogenic risks to their future children who have been conceived naturally or by fertility treatment. The data available in the literature may reassure the medical community that there is no such increased risk. However, due to the relatively small number of children born after such treatment, a long-term follow-up is required. There is an ongoing debate regarding the justification for the programme due to the small number of patients who make use of their banked spermatozoa. The authors believe in the importance of protecting the fertility potential of cancer patients, enabling them to father their genetic children in the future while fighting their illness.

Assessment of ovarian reserve - is there a role for ovarian biopsy?

The pool of primordial follicles in the ovary or 'ovarian reserve' is a major factor in the human fertility potential. The ageing ovary is characterized by reduction of the number of primordial follicles and this loss accelerates in the late 30's and precedes the menopause by 10-12 years. Woman's age alone or with a combination of biochemical markers, dynamic tests and ultrasound measurements fail to predict this loss accurately. In this manuscript, a novel approach of histopathological examination of ovarian biopsy for the evaluation of infertility, especially in unexplained infertility and in women in the later part of reproductive life, is discussed.

How do patients choose private in vitro fertilization treatment? A customer survey in a tertiary fertility center in the United Kingdom

OBJECTIVE

To assess the relevant factors affecting patients' decision when choosing a clinic for private, self-funded IVF treatment.

DESIGN

Prospective anonymous closed questionnaires.

SETTING

Single tertiary-care private IVF center.

PATIENT(S)

New patients attending primary consultation in a period of 7 months from September 1999 to March 2000.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Primary knowledge about the clinic, source of referral, knowledge of, availability of information pack, and familiarity with the clinic's success rates and treatment's price. The last question assessed the relative importance of each factor in the decision-making process according to the SERVQUAL model, modified version. All items were measured as perceptions on a 5-point Likert scale. 1 = not important, 3 = neutral, and 5 = very important.

RESULTS(S)

One hundred seventy-five patients completed the questionnaire. They were well informed and investigated the market before making their final choice. Patients collect information from many sources, including new channels such as the Internet. Up to one third of patients do not consult their doctor before treatment. By far the most relevant factor in decision making is the success rate (i.e., delivery rates) of the clinic, followed by recommendation by general practitioner (GP) or consultant (respectively, Likert scale score, 4.6; 95% confidence interval [CI], 4.5-4.7; and Likert scale score, 4.0; 95% CI, 3.9-4.2; P<.01). Other factors, such as cost of the treatment, friends and relatives' opinions, and distance from home were not relevant.

CONCLUSION(S)

Units that wish to thrive and increase their market share should deliver high-quality service and concentrate their efforts on excelling in performance.

XX males without SRY gene and with infertility

The case of a 28 year old male with normal male phenotype, in whom repeated seminal analysis showed complete azoospermia, is presented. Peripheral blood culture for chromosome studies revealed 46 chromosomes with XX constitution. Polymerase chain reaction (PCR) analysis of genomic DNA failed to detect the presence of the sex-determining region of the Y chromosome (SRY). A literature review of all SRY-negative XX males with normal male phenotype showed that this case is the sixth reported case but the first to be diagnosed during the investigations of infertility. The frequency, aetiology and diagnosis of this rare syndrome are also reviewed.

IVF performance of women who have fluctuating early follicular FSH levels

OBJECTIVES

The aim was to evaluate whether women who have early follicular follicle-stimulating hormone (FSH) levels > 12 mIU/ml have reduced response to follicular stimulation for in vitro fertilization (IVF) in a following month, in spite of normal FSH levels.

MATERIAL AND METHODS

In a 3-year period from January 1996 to December 1998, 303 women aged 38 years and above and/or who had previously responded poorly to superovulation for IVF gave blood samples for FSH, luteinizing hormone (LH), and estradiol (E2) on day 2 of menstruation before commencing treatment.

RESULTS

In 117 (38.6%) of these women, FSH levels were > 12 mIU/ml (range 12-114 mIU/ml). Sixty-six of these women gave a further 130 blood samples for FSH measurement in the following months. Seventy-eight (60.0%) of the tests showed raised FSH value > 12 mIU/ml. Thirty women whose repeat FSH levels were < 12 mIU/ml underwent 41 IVF cycles (group 1). Sixty-three other women, older than 38 and/or who had a poor response to superovulation previously and whose FSH levels were < 12 mIU/ml, served as the control group (group II). There were no differences in the responses to superovulation and delivery rates between the two groups (14.6% vs. 12.7%).

CONCLUSIONS

Women whose early follicular phase FSH levels were raised > 12 mIU/ml had an increased risk (> 50%) that in subsequent cycles levels would remain raised, and it was not possible to predict which individuals would have favorable FSH levels. If the cycle day 2 FSH level returns to a "normal" level of < 12 mIU/ml, women aged 40 and above had substantial cycle cancellation rates (43%), but patients who achieved the stage of embryo transfer had a good chance of conceiving, regardless of their age.

Effect of coenzyme Q(10) and alpha-tocopherol content of mitochondria on the production of superoxide anion radicals

The effects of coenzyme Q(10) (CoQ(10)) and alpha-tocopherol on the rate of mitochondrial superoxide anion radical (O2(./-)) generation were examined in skeletal muscle, liver, and kidney of 24-month-old mice. Mice were orally administered alpha-tocopherol (200 mg.kg(-1).day(-1)) alone, CoQ(10) (123 mg.kg(-1).day(-1)) alone, or the two together for 13 wk. Administration of alpha-tocopherol resulted in an approximately sevenfold elevation of mitochondrial alpha-tocopherol content. Intake of CoQ(10) alone caused an approximately fivefold increase in CoQ content (CoQ(9) and/or CoQ(10)) and alpha-tocopherol of mitochondria. The rate of (O2(./-)) generation by submitochondrial particles (SMPs) was inversely related to their alpha-tocopherol content but unrelated to CoQ content. Experimental in vitro augmentation of SMPs with varying amounts of alpha-tocopherol caused an up to approximately 50% decrease in the rate of O2(./-) generation. Similar in vitro augmentations of SMPs with CoQ(10) had previously been found to have no effect on the rate of O2(./-) generation The CoQ(10)-induced elevation of alpha-tocopherol in the present study was inferred to be due to a 'sparing/regeneration' by CoQ. Results indicate the involvement of alpha-tocopherol in the elimination of mitochondrially generated O2(./-)

How useful is cervical dilatation in patients with cervical stenosis who are participating in an in vitro fertilization-embryo transfer program? The Bourn Hall experience

OBJECTIVE

To evaluate the place of cervical dilatation performed at the initial visit in an IVF-ET cycle in patients with known cervical stenosis.

DESIGN

Retrospective study.

SETTING

A tertiary care assisted conception unit.

PATIENT(S)

Fifty-seven patients who failed to conceive after a previous ET attempt and in whom the ET was classified as "difficult."

INTERVENTION(S)

Cervical dilatation under general anesthesia after pituitary suppression and before gonadotropin stimulation.

MAIN OUTCOME MEASURE(S)

Ease of the ET procedure and clinical pregnancy rate.

RESULT(S)

Eighteen (31.6%) of 57 women who failed to conceive after a previous attempt at IVF-ET achieved a clinical pregnancy after cervical dilatation. In 40 patients (70.2%), the subsequent ET was classified as "easy," whereas in the other 17 (29.8%), it remained difficult. The pregnancy rate was significantly higher when the ET was easy than when it was difficult (40% versus 11.8%, P<.05).

CONCLUSION(S)

In patients with cervical stenosis and a previous difficult ET, cervical dilatation during the initial visit leads to an easier subsequent ET and improves the pregnancy rate.

The effect of endometrial polyps on outcomes of in vitro fertilization (IVF) cycles

PURPOSE

Our purpose was to investigate the effect of endometrial polyps on pregnancy outcome in an in vitro fertilization (IVF) program.

METHODS

Endometrial polyps less than 2 cm in diameter were suspected by transvaginal ultrasound before oocyte recovery in 83 patients. Forty-nine women (Group I) had standard IVF-embryo transfer, while in 34 women (Group II) hysteroscopy and polypectomy were performed immediately following oocyte retrieval, the suitable embryos were all frozen, and the replacement cycle took place a few months later.

RESULTS

Of the 32 hysteroscopies, a polyp was diagnosed in 24 cases (75%) and polypoid endometrium in another 5 patients (15.6%). An endometrial polyp was confirmed by histopathological examination in 14 women (58.3%). The pregnancy rate in group I was similar to the general pregnancy rate of our unit over the same period (22.4 vs 23.4%) but the miscarriage rate was higher (27.3 vs 10.7%, P = 0.08). In Group II, the pregnancy and miscarriage rates were similar to those of the frozen embryo cycles at Bourn Hall (30.4 and 14.3 vs 22.3 and 12.1%, respectively).

CONCLUSIONS

Small endometrial polyps, less than 2 cm, do not decrease the pregnancy rate, but there is a trend toward increased pregnancy loss. A policy of oocyte retrieval, polypectomy, freezing the embryos, and replacing them in the future might increase the "take-home baby" rate.

The fertility potential of women with a single ovary

The incidence of having a single ovary is quite common in infertile patients and can reach up to 17% of women with severe tubal disease who require in-vitro fertilization (IVF) treatment. Data on the short- and long-term implications of having only one ovary are scarce, and patients in this situation are naturally concerned. This article reviews the effect of possessing a single ovary on the fertility potential and ovarian reserve of these women and their performance in assisted reproduction treatment.